Nse 103 week 1
the first phase of the nursing process, involves collection of analysis of clie
what is health assessment
data. It is an ongoing process throughout the patients stay
- Any health assessment performed must fall under the nursing scope of
practice and be informed by the appropriate nursing College or associated
practice standard
Health assessment: related legislation - CNO is the legal governing body for nurses, so a health assessment must
performed based within the CNO legislated scope of practice, the practice
standard, and based on your individual level of competence (i.e., knowledg
and expert practice to perform an action)
What is subjective data? information that a client net or another person shares regarding the clients
P> provocative (what makes the symptoms worse)
Q>quality (what does it feel like) quantity ( tell me how bad the pain is)
qualification
R> region (where is it) radiation (does it move anywhere)
Questions to ask patients
S>severity ( on scale) quantification
T>Timing (when did it start/what were you doing) Treatment (have you treat
with anything)
U> understanding (what do you think is going on) look at symptoms and sig
Information the nurse observes when conduction a physical examination
what is Objective data?
(collecting lab and diagnostic results)
, Nse 103 week 1
1. Respiration
Measurements in order from 1-5 when 2. Pulse
taking vital signs on a newborn who is 3. Oxygen saturation
not in distress 4. Temperature
5. Blood pressure
Knowledge of accurate vital signs ranges for the age of the person (an infa
have a highway pulse than an adult)
Consider the following when analyzing
Knowledge of a person's trends in vital sign measurements (this shows if the
vital signs measurements
person is getting better or deteriorating)
Knowledge of a person's baseline vital signs
To facilitate clinical judgment. ( A determination about a client's health and
illness status
What is the purpose of an health Their health concerns and needs
assessment? The capacity to engage in their own care
The decision to intervene/act or not if action is required then what action is
needed)
Determine if the collected data represented are normal findings or abnorm
how do you facilitate clinical judgment?
findings
, Nse 103 week 1
1. Recognize cues
2. Analyze cues/ prioritize hypothesis
clinical judgment process 3. Generate solutions
4. take action
5. Evaluate outcomes
Recognize cues Relevant/important cues/immediate concerns
Why is the cue of concern? How do the cues relate to one another? What o
Analyze cues
information is important to collect to determine the significance of a cue?
What explanations are most/least likely? Which explanations are the most
Prioritize hypothesis
serious?
What are the desirable outcomes? What interventions can achieve this
Generate solutions
outcome? What actions should be avoided?
Take action What actions/interventions are of highest priority?
What signs point to improving/unchanged/declining status?
Evaluate outcomes Where the actions/interventions effective? How do you know they were
effective?
the first phase of the nursing process, involves collection of analysis of clie
what is health assessment
data. It is an ongoing process throughout the patients stay
- Any health assessment performed must fall under the nursing scope of
practice and be informed by the appropriate nursing College or associated
practice standard
Health assessment: related legislation - CNO is the legal governing body for nurses, so a health assessment must
performed based within the CNO legislated scope of practice, the practice
standard, and based on your individual level of competence (i.e., knowledg
and expert practice to perform an action)
What is subjective data? information that a client net or another person shares regarding the clients
P> provocative (what makes the symptoms worse)
Q>quality (what does it feel like) quantity ( tell me how bad the pain is)
qualification
R> region (where is it) radiation (does it move anywhere)
Questions to ask patients
S>severity ( on scale) quantification
T>Timing (when did it start/what were you doing) Treatment (have you treat
with anything)
U> understanding (what do you think is going on) look at symptoms and sig
Information the nurse observes when conduction a physical examination
what is Objective data?
(collecting lab and diagnostic results)
, Nse 103 week 1
1. Respiration
Measurements in order from 1-5 when 2. Pulse
taking vital signs on a newborn who is 3. Oxygen saturation
not in distress 4. Temperature
5. Blood pressure
Knowledge of accurate vital signs ranges for the age of the person (an infa
have a highway pulse than an adult)
Consider the following when analyzing
Knowledge of a person's trends in vital sign measurements (this shows if the
vital signs measurements
person is getting better or deteriorating)
Knowledge of a person's baseline vital signs
To facilitate clinical judgment. ( A determination about a client's health and
illness status
What is the purpose of an health Their health concerns and needs
assessment? The capacity to engage in their own care
The decision to intervene/act or not if action is required then what action is
needed)
Determine if the collected data represented are normal findings or abnorm
how do you facilitate clinical judgment?
findings
, Nse 103 week 1
1. Recognize cues
2. Analyze cues/ prioritize hypothesis
clinical judgment process 3. Generate solutions
4. take action
5. Evaluate outcomes
Recognize cues Relevant/important cues/immediate concerns
Why is the cue of concern? How do the cues relate to one another? What o
Analyze cues
information is important to collect to determine the significance of a cue?
What explanations are most/least likely? Which explanations are the most
Prioritize hypothesis
serious?
What are the desirable outcomes? What interventions can achieve this
Generate solutions
outcome? What actions should be avoided?
Take action What actions/interventions are of highest priority?
What signs point to improving/unchanged/declining status?
Evaluate outcomes Where the actions/interventions effective? How do you know they were
effective?
